Human Resource Management

Assessments in Ethiopia: Synthesis

Report

Management Sciences for Health, September 10,

2013

Submitted by MSH on behalf of the “Strengthening Human

Resources for Health (HRH) Program” funded by USAID.
Table of Contents
EXECUTIVE SUMMARY .................................................................................................................................3
INTRODUCTION AND BACKGROUND ...............................................................................................5
Country Situation .........................................................................................................................................5
Strengthening Human Resources for Health Program.........................................................................5
Regional Health Bureau Structure ............................................................................................................6
HRM Rapid Assessment Tool and administration.................................................................................7
METHODOLOGY ...........................................................................................................................................8
Interpretation of Results .............................................................................................................................9
Action Plans ...................................................................................................................................................9
Findings ...........................................................................................................................................................9
Comment on Findings .............................................................................................................................. 15
Recommendations ..................................................................................................................................... 16
CONCLUSION.............................................................................................................................................. 16
Appendix: The HRM Rapid Assessment Tool ......................................................................................... 17

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EXECUTIVE SUMMARY
The Strengthening Human Resources for Health (HRH) Project is a five year bilateral program
(2012-2017), funded by USAID, with an overall goal of improving the human resources for
health status in Ethiopia. Some of the HRH challenges that Ethiopia faces include health worker
shortages, low retention, and weak human resource management systems. Strong and effective
human resource management systems are required to overcome these challenges.
To assess the human resource management systems and practices in Ethiopia’s regional health
bureaus, as well as that of the Ethiopia Midwives Association (EMA), a Human Resource
Management (HRM) Rapid Assessment was carried out in the country’s 11 regions between
January 18 and May 19, 2013. Management teams in each region and EMA will use the results
to develop strategies to improve their current system and make it as effective as possible. The
staff in each region developed an action plan and timeline to implement the strategies that,
when implemented, will improve the overall HRM system. The action plans are based on
priorities identified in each Region and the EMA.
The assessment was carried out with health managers using MSH’s “Human Resource
Management Rapid Assessment Tool for Public and Private Sector Health Organizations, 3rd
Edition.” This tool is a methodology used to identify the strengths and weaknesses of an
organization’s human resource management system and help the organization to develop action
plans for improving its human resource system.
Key findings of the assessments across all 11 regions include:

• Existing HR staff have limited technical skills and experience in HRM.

• There is a limited budget, or non-existent budget dedicated to HRM activities such as
staff training and other operational activities.
• There is no system in place for comprehensive HR planning.
• HR policies and procedures are not consolidated into an HR manual and are not
accessible to staff.
• There is no orientation program for new staff. Existing job classification, recruitment,
compensation, deployment and discipline policies and procedures are not applied
consistently.
• An HIV/AIDS program is not fully implemented or understood by staff.
• The HRIS is not fully functional and has a huge data backlog and a critical shortage of
computers.
• Employee data collection is incomplete and there are no staff dedicated to this role.
• No data on staff turn-over or retention is available except at some hospitals and there is
no established mechanism to collect this data.
• Supervision is ad hoc, and the system is not widely understood or used.
• The performance appraisal system is not strong and the proposed Balanced Score Card
(BSC) system is yet to be tested. Existing performance appraisal practices are not linked
to rewards or sanctions mechanisms.
• Although regional health bureaus provide some in-service training opportunities, these
are limited to health programs with little relevance to operational management including
HRM areas. In general, training is not linked to employee and organizational
performance needs.
• There is no initiative to develop leadership and management skills in HRH.

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 • The regional bureaus have limited links with the private health science institutions (as
these institutions report to Technical and Vocational Education and Training Agencies in
most regions) and no links to the universities.
The results of the HR Rapid Assessment were consistent across the regions, regardless of
individual regional characteristics. In all cases, the lack of trained HRM staff was at the top,
followed by a lack of budget for HRM activities (aside from compensation and recurrent costs)
and a lack of HR Planning. All regions identified the lack of a computerized system to gather
information on staff and staffing needs on a consistent basis as a priority, seeing HR data as an
essential ingredient to improving planning and management. In addition, the regions identified
the lack of any initiative to develop HRH leadership and management capacity as a critical
weakness in the system.

Not surprisingly, these same components were given a high priority in the action plans. Given
that the goals of the action plans will require support from the national level, there is a need for
collaboration to improve the system. It must also be understood that a concurrent initiative to
professionalize the cadre of HR managers is necessary in order to implement sustainable
change.

The Ethiopian Midwives Association reported similar findings, except that their assessment
showed a marked difference in five areas:

• The EMA staff have more experience in the field of HRH.

• EMA has a well-documented and up-t-o-date policy manual.
• Employee data is available and used for decision making.
• Computers are available for computerization of data but the organization lacks a
database, software or staff trained in HR data management.
• Job descriptions are updated annually as part of the performance appraisal plan.

Both the EMA and the regions are moving forward to implement their action plans.

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INTRODUCTION AND BACKGROUND
Country Situation
Ethiopia continues to suffer a considerable disease burden and critical shortages of health
workers. Ethiopia has the seventh highest burden of tuberculosis in the world. While high
incidence of communicable diseases, including tuberculosis, malaria, respiratory infections,
diarrheal diseases and nutritional deficiencies plague the population, women and children
remain disproportionally vulnerable. Several critical factors affect the quality of the current
human resources for health system:

1. Attrition of skilled health care workers: The health care worker shortage is compounded by
high rates of health worker attrition. Among the factors contributing to high rates of
attrition across cadres are: the inadequacy of medical equipment/supplies; lack of clear
job descriptions and skilled human resource managers; poor and ad-hoc supportive
supervision; little access to continuing professional development (CPD); and poorly
defined career.

2. Inequitable distribution of the health workforce: The higher attrition rates in rural areas are
compounded by the limitations of the human resources information system (HRIS) to
track placement, skills and performance of health workers. Even as current recruitment
strategies in Ethiopia fail to address retention, insufficient medical equipment and
supplies, along with meager benefits packages, serve as disincentives for workers to
remain at rural areas.

3. Ineffective management of human resources for health systems: A lack of dedicated and
trained human resources managers has stymied progress in implementing human
resources strategies and transforming existing human resources strategies and plans into
a comprehensive, harmonized, systemic approach that is effectively implemented and
sustained.

Although these challenges persist, progress has been made in Ethiopia. The Health Sector
Development Program (HSDP) of the Government of Ethiopia is in its fourth phase (HSDP IV).
The first, second and third phases of the HSDP have increased the number of health care
facilities within a three-tiered health system reaching from specialized urban hospitals to
satellite rural health posts. Business process re-engineering has been used to identify and make
systemic improvements. Efforts to date have included a very successful and aggressive scale-up
of Health Extension Workers (HEWs), increased attention to the production of midwives and
anesthetists, and development of master’s level programs for emergency surgery and obstetrics
for health officers needed to reduce maternal mortality.

Strengthening Human Resources for Health Program

The Strengthening Human Resources for Health (HRH) Project is a five-year bilateral program (2012
– 2017), funded by USAID, with an overall goal of improving the human resources for health

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status in Ethiopia. In order to achieve this goal, the Jhpiego-led consortium with Management
Sciences for Health (MSH), Ethiopian Midwives Association (EMA), Ethiopian Association of
Anesthetists (EAA) and the Open University (OU) is supporting the Government of Ethiopia by
addressing challenges related to poor quality of pre-service education (PSE), attrition of skilled
workers, inequitable distribution of the workforce, ineffective management and lack of
regulatory capacity of human resources for health in the county. To this end, the project has
four major result areas further disaggregated into several sub-results. The four major result
areas are:

- IR I. Improved Human Resources for Health Management

- IR2. Increased Availability of Midwives, Anesthetists, HEWs and essential non-clinical
Health Workers
- IR3 Improved Quality of Training of Health Workers
- IR4. Program Learning and Research Conducted.

The first result area of the project focuses on strengthening the human resource management
system and practices all the way from the Federal Ministry of Health to Woreda-Sub city Health
Offices levels. Result areas 2 & 3 respectively focus on increasing the availability and improving
the quality of pre-service training of critical health workers. Result 4 focuses on systematic
program learning through research and routine monitoring and evaluation; it is cross cutting
and applies for all the other three result areas.

The project strengthening efforts will be carried out in all 11 regions of the country. In support
of Result Area 1: Improving Human Resources for Health Management, the project has assigned
Human Resource Management Officers who will be dedicated to supporting the regions
Assessing the human resource management system in the regions and how well they currently
function is a necessary prerequisite to designing effective strategies for improvement. To
accomplish this, assessments were carried out in each region using the Human Resource
Management Rapid Assessment Tool for Health Organizations.

Regional Health Bureau Structure

All regional health bureaus have slightly different organizational structures based on the needs
identified through regional business process re-engineering (BPR) exercises. However, all
regional health bureaus have core work processes and support work processes. Core
processes are related to disease prevention, health promotion and essential curative services
while support process is related to finance and administration, human resources management
and other operational functions.

Both the core processes and the support processes are further divided into sub-processes.
However, the numbers of sub-divisions vary from a region to another region. For example,
Amhara Regional Health Bureau is organized into seven core processes and five support
processes. The core processes include:

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 1. Health Promotion and Disease
prevention
2. Curative and Rehabilitative services
3. Public Health Emergency
Management
4. Health and Health Related products
and service Regulatory
5. Research and Technology Transfer
6. Health Commodities Supply
7. Public Relation

In addition to the core processes, Regional Health Bureaus have five support processes which
include:

1. Human Resource Management

2. Planning, Monitoring and Evaluation
3. Procurement, Finance and Property Management
4. Financial and Performance Audit
5. Civil Service Reforms

HRM Rapid Assessment Tool and administration

The HRM Rapid Assessment for each region was conducted using the MSH “Human Resource
Management Rapid Assessment Tool for Public and Private Sector Health Organizations, 3rd
Edition” (see Appendix 1). The HRM Rapid Assessment tool has been designed for use by health
managers to assess the strengths and weaknesses of their organization’s HRM system and
develop an action plan to strengthen it. Health managers, policy and decision makers at all levels
of the health system can effectively use this tool.

The instrument itself consists of a matrix that includes:

- Five broad areas in HRM: HRM capacity, Personnel Policies & Practice, HRM Data,
Performance Management, Training & Staff Development
- Twenty components within the five broad areas represent the core functions of an
effective human resource system
- Each of the twenty components has four stages of development
- Characteristics that describe each human resource components at each stage of
development
- Blank spaces for users to write a brief statement, or indicator, to show how the
organization fits a particular stage of development, i.e., the evidence. See the example of
one of the components on the following page.
Personnel files for individual employees, one of the three components under broad area-HRM
data
Broad Component Stages of development Evidence
Area 1 2 3 4 (Indicators)

Personnel No Limited Personnel Updated

Files individual employee files for all personnel files
employee personnel employees for all
records file are are employees
exist maintained, maintained exist and also
(Individual
HRM Data

but not and kept policies for

employee
regularly up-to-date, appropriate
records)
updated but there use (e.g.,
is no confidentiality,
policy for employee
employee access)
access or
use this
data

Based on the set of characteristics describing the stages of development of a fully functioning
Human Resource Management System, the tool provides a process through which an
organization can assess how well it is functioning in relation to each of these 20 components and
determines what steps it can take to function more effectively.

METHODOLOGY
The assessment was launced at a workshop organized by MSH. A maximum of 20 participants
attended the Workshop, consisting of a range of health mangers and staff. In many regions, the
head of the deputy regional health bureau opened the workshop by emphasizing the importance
of strengthening the human resources function at regional and sub-regional levels to achieve
health sector goals including international initiatives such as the Millennium Development Goals
(MDGs), and fighting tuberculosis, malaria and HIV/AIDS.

Objectives: The workshop was framed around five objectives (below).

- To create shared understanding about the human resources for health (HRH) crisis in
Ethiopia with particular emphasis on the regional context
- To discuss Human Resources Management (HRM) and its key components for practical
applications
- To introduce HRM capacity assessment process and tools
- To identify HRM gaps and priority areas for intervention and develop action plans for
improving HRM systems, policies and practices

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 - To create participatory learning environment, momentum for organizational learning and
growth

Interpretation of Results
The tool provides guidelines that help the participants interpret their results. While all of these
HRM components, taken together, are needed to make up an effective HRM system, there is an
underlying order of priority. For example, without well trained HR managers in place, none of
the other components can be developed and managed. Likewise, professional HR managers
require a budget to support their activities and a HR Plan upon which to build an adequate
workforce.

Once the priority objectives are agreed on, the participants began to identify activities to
address the high priority areas. In this process, the guidelines propose that they focus on actions
that:

• Can be accomplished quickly and require few resources

• Will have the biggest impact on organizational goals, even if they take longer to
accomplish
• Will provide a basis for many other activities

While it is important to focus first on a manageable number of components, it is also important

to remember that the long-term effectiveness of HRM is achieved only when all of the
components described in this tool are addressed in an integrated manner. For example, a focus
on building the capacity of HRM staff is unsustainable if changes are also not made to the level of
training and experience required for the job in the first place.

Action Plans
Once the priority areas and strategies were agreed to, the regional groups developed an action
plan. They were guided in this by looking at the HRM Tool and the characteristics at the next
higher stage of development for the HRM component they were addressing.

Findings
The following regions, city administrations and the EMA submitted reports and action plans:

1. Afar Region 7. Addis Ababa city administration

2. Amhara Region 8. Benishangul-Gumuz Region
3. Oromia Region 9. Gambela Region
4. Somali Region 10. Harari Region
5. SNNPR Region 11. Dire Dawa city administration
6. Tigray Region 12. Ethiopian Midwives Association (EMA)

The reports were consistent in their format. Some regions did both a priority action plan and a
complete action plan; some regions did one action plan, but indicated which components were
priorities.

The listings below illustrate the findings of the regional and city administration meetings.
Despite regional differences, a set of six priority components cut across all regions:

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Six priority components across all regions:

1. HRM staffing 5. Employee Data

2. Computerization of Data 6. Management and Leadership
3. HRM Budget Development for Staff
4. HRM Planning

These six components are followed by:

7. Orientation Program for New Staff 12. Compensation

8. Personnel Files for employees 13. Personnel files
9. Retention strategy
10. Supervision 14. In-Service Training
11. In-Service Training

Action Plans for the Six Priority HRM Components

While the action plans are not identical, they specify many actions in common. In addition, all of
them indicate that they need technical and financial assistance to be implemented, e.g., hiring
additional computer data staff. Many regions indicate that they need the approval of the
Regional Civil Services Bureau (RCSB). In the case of financial assistance, or additional budget
required, many regions indicate that they need support from HRH project, LMG project,
Tulane University, technical assistance in Ethiopia, UNFPS, and/or other partners.

The following actions are illustrative of actions in common as described in the action plans.

1. HRM staff: HRM staff are staff that are dedicated to and responsible for HRM. It is
critical that this component be addressed in the beginning as the health sector cannot
carry out its HRH strategy without trained and professional HR managers at all levels.

- Review existing HR structure and HR staffing needs at the regional and Woreda levels
- Recruit additional HR staff where needed
- Conduct HRM functions audit of skills needed to build the capacity of HRM staff to
carry out their jobs
- Provide training for HRM staff
- Revise minimum education/skills required for HR manager posts so in the future only
qualified individuals will be hired for these positions.

2. Computerization of Data: HR data is routinely entered into a system so that it is

available to health mangers. Accessible, accurate and timely data is essential for good
planning.

- Increase the number of computers at the regional/Woreda levels

- Identify critical factors and corrective measures needed to implement the HRIS
- Train staff on how to use the system

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 3. HR Budget: Funding for related HR activities, in addition to compensation and
benefits, is available. Prepare a specific budget for HR activities needed to support the
HRM system, i.e., in-service training, prepare HR manual

- Present the plan and budget to the Regional Cabinet for approval
- Monitor and evaluate the implementation of support activities

4. HR Planning: Planning is a forecast of the number of staff in different cadres who will
be needed to meet the health goals of the Ethiopia National Health Plan.

- Develop HR Planning skills of HR staff in order for them to forecast HR staffing needs
- Develop a comprehensive 5-year staffing plan for the region
- Build capacity of hospitals, Woredas, and health science colleges to develop staffing plans

5. Employee Data: This is key information on individual staff, their skills, their job title,
their salary, their location, education level, and years of experience. It allows for a
complete HRIS system and also for appreciates allocation and training of staff and,
tracking of personnel costs.

- Update the existing data collection tools

- Collect timely HRM data (quarterly)
- Train staff on data collection and storage

6. Management and Leadership Development are critical to sustainability.

There should be a plan in place and opportunities for everyone to participate in
management and leadership development, based on their performance and other
established criteria.
- Conduct needs assessment
- Identify in-service training opportunities for leadership and management development
- Partner with LMG to provide leadership and management training to HRM staff
- Visit with other teams.

See the matrix on page 13 for a summary of the data from the regional assessments.

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MATRIX: Findings from Regional and City Administration HRM Assessments

1 2 3 4 Number of Summary of Comments/

regions who Evidence
identified this
component as
a priority in
their action
plan
Summary of HRM Stage of Development identified (see descriptions of stages in Annex 1)
10 1 10 Staff in HR positions meets minimum requirements of RHB,
but lack experience and training. In some cases, they are
HRM Staff assigned to other duties, not HR. Most staff lack basic
professional training and there are vacant posts in HRM as
the sub process.
11 7 HR budget exists for salaries and recurrent costs, but is
very limited for HR activities, i.e., training, orientation
HRM programs, supervision, printing of HR manuals and related
Budget HR activities.
1 8 2 8 No system for comprehensive HR planning exists, one that
is based on HR audit, forecasting, and budget. Existing
HR
plans are not need based. Often, the HR manager is not
Planning
involved.
Personnel Policy and Practice
4 7 1 Classification system exists, but it is not systematically
applied and not used for salary, benefits. The job
Job
classification system is not used for other HR functions, i.e.,
Classificati
planning, job descriptions, salary.
on System

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 9 2 3 There is a formal, structured system in place, but not
Compensa applied in a systematic way. In some cases, two of the same
tion and jobs have different salary scales.
Benefits
S
Recruitme 1 10 2 Procedures are in place, but are not applied consistently.
nt, Hiring,
Transfer
and
Orientatioi 9 2 7 Orientation programs are not structured, and are applied
n Program irregularly.
for New
Staff
1 4 6 Manuals exist, but are not complete and not accessible to
Policy employees. There is no employee handbook.
Manual

Discipline, 4 7 1 Guidelines exist, but are not applied systematically.

Terminati
on and
Grievance
HIV/AIDS 4 6 1 4 Programs exist, but are not regularly monitored or
Workplac reviewed. Staff contributes 2% of salary. Other health
e workplace safety programs are addressed in a variety of
Prevention ways, but not consistently.
Program
HRM Data
10 1 8 Data collection lacks formats and instruments, and staff
skills to analyze and properly utilize it. Data collection is
Employee Data
inconsistent, incomplete and poorly managed due to lack of
staff.
1 6 4 9 The system is not fully functional. There is a shortage of
Computerizati data clerks and clerks do not receive training. There is a
on of Data huge data backlog and a critical shortage of computers at
the zonal and work levels.

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Personnel file
10 1 5 Files are incomplete, not regularly updated and difficult to
access.
Performance Management
Staff Retention
9 2 5 There is no data on staff retention, except at hospitals, and
no established mechanism to collect it, identify the root
Strategy
causes for attrition or to address staff turnover.
Job
6 5 4 Job descriptions do exist according to a structured BPR
system, but they do not include specific duties and/or
Descriptions responsibilities.

Staff
1 9 1 4 A line of authority exists, but the system is not widely used
or understood, so there is minimal supervision on an ad-
Supervision hoc basis.
Work Planning 3 5 3 2 A Business Score Card based on work planning and
and performance review is developed, but not tested. It will
Performance have to be adapted for lower levels of staff.
Review
Training and Staff Development
Staff In-Service
1 10 4 There is no structured plan or data base for in-service
training and trainings are not need based. Its impact is not
Training
evaluated
Management 2 9 5 There is a regional plan on management and leadership but
and Leadership it is not budgeted or implemented.
Development
for Staff
Links to 1 9 1 3 The regional health bureaus have links to health science
External Pre- colleges in their region, but lack any link to universities.
Service
Training

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Ethiopian Midwives Association

The Ethiopian Midwives Association (EMA) is a partner on the Strengthening of Human Resources
for Health (HRH) Project. The EMA was established as a professional association in 1992 and
engages in several activities that benefit midwives and community at large. Its vision centers on
excellence by enhancing and promoting the midwifery profession; partnership and modeling
best practices to inform health policy; and programs for the betterment of the health of
Ethiopian society through capacity building, advocacy and representation, partnership and
resource mobilization and research, monitoring and evaluation.

The objective of the Human Resource Management (HRM) Rapid Assessment exercise for EMA
was to explore the current status of the organization’s human resources management systems
and functions, identify gaps and bottlenecks, and develop action plan.

The assessment was carried out over one and half days with the organization staff’s with the
same tool that was used by the regional health bureaus. Following the assessment, the EMA
summarized its areas of HRM strength and weakness in the table below. They also developed
an action plan to address all components, with an emphasis on the areas of weakness.

EMA Results of HRM Assessment

Areas of HRM Strength (3 and 4 Areas of HRM Weakness (1 and 2 scores)
Scores)
• HRM Budget • HRM Staff
• HR planning • Compensation and benefits
• Job classification • Orientation program
• Recruitment, hiring, transfer and • HIV/AIDS workplace prevention program
promotion for staff
• Policy manual • Computerization of data
• Discipline, termination and grievances • Staff retention strategy
procedure • Staff in-service training
• Employee data • Management and leadership development
• Personnel files
• Job descriptions
• Staff supervision
• Work planning and performance review
• Links to External Pre-service training

Comments on Findings
The individual level reports are excellent in their clarity and reporting on the application of the
HRM Rapid Assessment Tool. They provide clear evidence in regard to the decisions made by

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the assessment teams. Further, the action plans formulate targets for desired performance, and
define next steps and the person(s) responsible. Successful lasting change is a gradual process,
so it is better to have set realistic goals and try to move from one step to another.

Recommendations
1. Review the activity plan and decide on realistic goals to be accomplished in the first
year.
2. Analyze the selected goals and answer the following questions in regard to their
implementation:
- Do you have the authority at the regional level to carry out activities to attain these
goals? If not, who do you need to collaborate with?
- Who are the people responsible for carrying out the activities and what technical
assistance might they need?
- What other types of support, budget, and/or tools might you require to be
successful?
- What kind of mechanism do you need to monitor progress?
3. Finalize your plan and develop a timetable.
4. Begin implementation immediately

CONCLUSION
Realistic expectations are often the key to success. The leadership of the RHBs should also
participate in the implementation of the activities and actively support them. It will be important
to circulate this report and its findings beyond the scope of the RHB as well in order to bring
attention to the importance of these issues and the delivery of health services in Ethiopia.

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Appendix: The HRM Rapid Assessment Tool

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